AHRQ's new tools to improve safety for patients with Limited English Proficiency March 14, 2013

Abt Associates | pg 2 Cindy Brach Agency for Healthcare Research and Quality Joseph Betancourt Disparities Solutions Center Melanie Wasserman Abt Associates Alexander Green Disparities Solutions Center

Abt Associates | pg 3 One more collaborator  Emils, born 10/10/2012

Abt Associates | pg 4 Presentation goals  Describe development and testing of 2 AHRQ tools to improve LEP patient safety: –TeamSTEPPS Training module –Guide for Hospital Leaders  Describe implementation successes and challenges  Hear from you whether/how you might use the tools

Abt Associates | pg 5 Background  8.5% of the U.S. population has limited English proficiency (LEP) (US Census Bureau, 2010)  Patient safety events more severe and more often due to communication errors for LEP patients (Divi et al. 2006, Flores 2005)

Abt Associates | pg 6 Background (Cont’d)  LEP patients are safer and have fewer readmissions with professional interpreters (Flores et al. 2003, 2005, Linholm et al. 2012)  Health care providers often try to “get by” without interpreters (Diamond et al. 2009; Ring et al. 2010)  This can cost hospitals millions (Price-Wise 2008; Quan 2010; Carbone et al. 2003)  Even when interpreters are present, they may not be empowered to speak up when they see a patient safety risk (Betancourt et al. 2012)

Abt Associates | pg 7 AHRQ’s response  Commissioned an evidence-based Hospital Guide and TeamSTEPPS training module to improve LEP patient safety  TeamSTEPPs is AHRQ and DoD’s patient safety initiative  These are the first patient safety tools designed for LEP patients

Abt Associates | pg 8 Preliminary Research Questions  How do language barriers and cultural factors contribute to potential patient safety events?  How are hospitals addressing linguistic and cultural sources of error?  Which trainable team behaviors and hospital-level changes can improve LEP patient safety?

Abt Associates | pg 9 Preliminary Research Background Tool Development Environmental Scan Adverse Events Database Qualitative Interviews with Interpreters, Frontline Staff & Hospital Leaders Town Hall Meeting TeamSTEPPS Module Hospital Guide Interpreter pilot

Abt Associates | pg 10 Findings  Environmental scan results reported above  Stratified adverse events database analysis: –Less productive than anticipated due to data challenges: No standard field for patient language No field to record interpreter presence/absence –Hospitals at Town Hall meeting reported similar data challenges

Abt Associates | pg 11 Abt Associates Interpreter pilot and qualitative interviews  Common system failures: –Late or wrong identification of patient language needs –Non-qualified or non-use of interpreter –Failure to address interpreter shortages –Failure to integrate interpreter into patient safety team  Many stories about “close calls” or risky situations due to these issues

Abt Associates | pg 12 Abt Associates Late or wrong identification of language needs  Surgery intake in English  latex allergy almost missed, caught by interpreter called in at the last moment  Interpreter present but provider refusing their services  Wrong language used (Spanish/Portuguese, French/Creole) In French, estomac is the stomach, but in Creole, lestomak mwen means, ‘my chest’. Without an interpreter present, a French-speaking provider could incorrectly think a patient was experiencing stomach pain, not chest pain. This is a potentially life-threatening error. — Interpreter

Abt Associates | pg 13 Abt Associates “I try to say, ‘The interpreter’s coming.’ I try to stall. But it’s hard when somebody’s pushing and saying, ‘I have to go. My family member has been here waiting with me for the interpreter…’ ” —Nurse Maybe somebody else requires that bed. So that’s when we do our discharge. I would like to see the doctor’s face if I go over there, and say, ‘you know, I really can’t discharge this patient because he doesn’t really understand anything’ —Nurse Non-use of interpreter; failure to address shortages

Abt Associates | pg 14 I have noticed that the patients come back to the hospital, to the same units where they have already been discharged. So you give the paperwork to the patient the day that they are going home. Suppose I did not speak the language. The patient actually said, “yes yes yes yes I understand everything”. And then you find the patient back a few days later, a week later…the same patient. And then, that’s when I find out that every discharge instruction that was given to the patient was totally…it was just…it didn’t work at all. —Nurse

Abt Associates | pg 15 Abt Associates “I’ve seen interpreters try, for example, to intervene when a provider insists on speaking a language they’re not fluent in. And there’s a big power struggle and the interpreters feel intimidated. But it’d be nice for them to be able to really recognize situations that are really critical, to be able to call time outs” — Interpreter Services leader “The role of the interpreter is what we call black box. The role…is to render the words only” — Patient safety leader Failure to integrate interpreter into patient safety team

Abt Associates | pg 16 Abt Associates Improve LEP safety by helping hospital leaders to:  Foster a Supportive Culture for Safety of Diverse Patient Populations.  Adapt Current Systems To Better Identify Medical Errors Among LEP Patients.  Improve Reporting of Medical Errors for LEP Patients.  Routinely Monitor Patient Safety for LEP Patients.  Address Root Causes To Prevent Medical Errors Among LEP Patients Hospital Guide Goals

Abt Associates | pg 17 Abt Associates  What we know about LEP and patient safety  Strategies and tools to improve patient safety systems  Team behaviors to improve LEP patient safety  Additional resources and case examples Hospital Guide Content

Abt Associates | pg 18 Abt Associates Hospital Guide Testing  Shared with leaders in quality and safety at 9 hospitals  Leaders shared with their implementation teams (eg: interpreter leads, nursing leads)  Structured 30 mn interviews with leaders about content, usability, ease of implementation, and overall design and structure  Qualitative data analysis to identify key themes and implications for hospital guide  Edits made accordingly

Abt Associates | pg 19 Module Goals and Content  Goals: help hospital staff to improve LEP safety by: –Understanding risks to LEP patients –If LEP  calling a professional medical interpreter –Identifying and raising patient communication issues  Content: –Customizable PowerPoint slides, videos, exercises –Structured communication tools –Evaluation guide

Abt Associates | pg 20 Abt Associates Process Map Exercise

Abt Associates | pg 21 Abt Associates Stop the Line: Use CUS Words Structured communication tool to flag patient safety risks Empowers everyone on the team to stop the line Cues everyone on the team to pay attention if these words are used

Abt Associates | pg 22 Abt Associates Check-Back Tool

Abt Associates | pg 23 Field Test  Case study design –ToT, 5 month follow-up, field visit  Requirements to participate: –No $ incentive –Send 2 trainers to ToT –Implement in at least 1 unit –Train the entire team –Evaluate

Abt Associates | pg 24 Successes  Module implemented 3 hospitals –Hospital #1: L&D –Hospital #2: ED, OB/Gyn –Hospital #3: Pediatric primary care  Focus of interventions: –Hospital #1: Use of qualified communicator –Hospital #2: Capturing patient preferred language –Hospital #3: Use of phone-interpreters  268 staff members trained including doctors, nurses, interpreters, registration staff

Abt Associates | pg 25 Quantitative Results Hospital #1 –Pre-test convinced leadership  no post-test Hospital #2 –High satisfaction (2.94 on 3-pt scale) –Significant increase in knowledge (up 28 points on 100-pt scale) –Race/ Ethnicity/Language (R/E/L) data quality issues  behavior data unusable Hospital #3 –High satisfaction (3 on 3-pt scale) –Increase in knowledge scores (up 17.6 points on 100-pt scale) –More phone interpreter minutes used but no LEP denominator

Abt Associates | pg 26 Qualitative Results  Recognition of interpreter as cultural broker  Willingness to include interpreter in care team  Reliance on CUS words/other techniques  Increased use of phone line (Hospital #3)  Institutional changes –Reallocation of interpreter resources (Hospital #1 & #3) –Plans to update hospital interpreter policy –Clarification of bilingual certification guidelines (Hospital #1)

Abt Associates | pg 27 Challenges  Time/cost concerns  Competing quality initiatives  Limited interpreter resources  Staff turnover  Equipment loss  Data quality for evaluation  Scale-up after the pilot

Abt Associates | pg 28 Practical advice  Implement the Guide and module to improve LEP safety –May be helpful to implement Joint Commission standards on patient-centered communication  Use creative scheduling and persistence to overcome barriers of time, cost and competing initiatives  Use interpreter resource reallocation as a stopgap until shortages are addressed  Check data availability/quality before finalizing evaluation plan

Abt Associates | pg 29 Take-home tools  Hospital Guide and Module available here:

Thank you!